Does autonomy enhance satisfaction, adherence and clinical outcomes? A Randomized Controlled Trial of a digital mental health intervention for college students

Background: College students face high rates of mental health problems including depression and stress. Digital interventions offer accessible support, but adherence remains challenging. Autonomy may enhance motivation, yet its role in student-focused digital interventions is not explored yet in a randomized controlled trial. Objective: This study examines whether enhancing autonomy in a guided digital CBT-based mental health intervention for college students (LifeHack) improves satisfaction, adherence, and mental health outcomes.Methods: In a two-armed randomized trial, 575 students were assigned to either a structured intervention or an autonomy-enhanced version in which participants could select topics of interest. Assessments were conducted at baseline and 5 weeks later (post-intervention). Primary outcomes were general satisfaction (CSQ-8) and working alliance with the program and e-coach (WAI-I); secondary outcomes included adherence, mental well-being (MHC-SF), depressive symptoms (PHQ-9), anxiety (GAD-7), and quality of life (MHQoL). Results: Participants were moderately satisfied with the intervention and guidance, and showed small-to-moderate improvements in mental well-being, depressive and anxiety symptoms, and quality of life from baseline to post-intervention (all p < .001; Cohen’s d ranging 0.24-0.41). However, no significant differences were observed between conditions on satisfaction, adherence or clinical outcomes.Conclusions: Allowing users to freely choose lesson topics did not enhance satisfaction, adherence, or clinical outcomes compared with a structured lesson sequence. Nonetheless, participation in LifeHack was associated with improved mental health, indicating potential intervention effectiveness regardless of the autonomy features. Future research should test more comprehensive autonomy-supportive designs and compare LifeHack with inactive control conditions to establish intervention effectiveness.